بسم الله الرحمن الرحيم

1. Taking patient history بسم الله الرحمن الرحيم

2. Definition The medical history or anamnesis of a patient: information gained by a physician or other healthcare professional by asking specific questions, either of the patient or of other people who know the person and can give suitable information (hetero-anamnesis), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient.

3. Importance:The information obtained in this way, together with clinical examination, enables the physician to form a diagnosis and treatment plan. Process: A physician typically asks questions to obtain the following information about the patient: 1- Identification and demographics: The name, age, height, weight.

4. 2- The "chief complaint (CC)“ the major health problem or concern, and its time course. 3- History of present illness (HOPI). 4- Review of systems (ROS), Systematic questioning about different organ systems. 5- Family diseases. 6- Childhood diseases. 7- Social history. 8- Allergies. 9- Regular medications.

5. 1- Demographics: • patient information that is not medical in nature. information to locate the patient, including identifying numbers, addresses, and contact numbers. • may contain information about race and religion as well as workplace and type of occupation, and the patient's health insurance. 2-Chief complaint: • This is the problem that has brought the patient to see the doctor indicating its nature and duration.

6. 3- History of the present illness: a- Onset. b- Location and radiation. c- Severity and character/quality. d- Duration and timing. e- Precipitating and palliating factors. f- Progression.

7. 4- Review of systems: • It is a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient. • It can be particularly useful in identifying conditions that don't have precise diagnostic tests.

8. 5- Family history: • Many doctors glean information on family morbidity of particular diseases (e.g. cardiovascular diseases, autoimmune disorders, mental disorders, diabetes, cancer) to appreciate whether a person is at risk for developing similar problems. • Use of a genogram can be helpful in a family history, which is in the format of a family tree.

9. 6- List of childhood diseases: Asthma, dental caries, candidiasis, Cytomegalovirus, Diabetes, Influenza and etc. 7- Habits: Various habits which impact health, such as tobacco use, alcohol intake, exercise, and diet are included, often as part of the social history.

10. 8- Allergy: • Risk factors for allergy can be placed in two general categories ( hostand environmental factors). Host factors include heredity, sex, race, and age, with heredity being the most significant. • Four major environmental candidates are alterations in exposure to infectious diseases during early childhood (environmental pollution, allergen levels, and dietary changes).

11. 9- Drug history (DH ): Do you take any (regular) medication? Tablets? Injections? Any over the counter drugs? Any prescriptions? Any herbal remedies? Contraceptive pill? Do you have any allergies? If none, record as NKDA (no known drug allergies).